KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN

DIREKTORAT JENDERAL KEBUDAYAAN

Komplek Kemdikbud Gedung E Lantai IV, Jl. Jend. Sudirman, Senayan, Jakarta 10270
Telepon 5731063, 5725035, 5725542 Fax 5731063, 5725578, 5725542

FORMULIR PENDAFTARAN
PEGIAT BUDAYA KE LUAR NEGERI 2016
1. IDENTITAS DIRI

NIK

Zulfredo Purba
Pas foto
: Bernard

Indonesia
: ....................................................................
3x 4
1272032407950001
:

Jenis Kelamin

:L/P

Agama
Tempa, Tanggal Lahir

: Kristen
Sambosar Raya, 24 Juli 1995
:

Alamat

Jl. Melati Raya no. 10, Perumnas Helvetia, Medan, 20124

:

Nama
Kewarganegaraan

No. Telepon/ HP
Alamat Surel
Instansi/ Lembaga
Alamat Instansi/
Lembaga
Pendidikan terakhir

+62-853-6117-1160
: ........................................................................................
bernard.bob24@gmail.com
: ........................................................................................
Institut Seni Indonesia Yogyakarta
:
Jl. Parangtritis km.6,5 , Sewon, Bantul, Yogyakarta
: ........................................................................................

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........................................................................................
SMA
:

2. BIDANG BUDAYA YANG DIPILIH

Musik
Bidang Budaya
: .......................................................................................
Profesi

Mahasiswa
: .......................................................................................

Riwayat Bekerja/

: .......................................................................................

Berkarya

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24 Juni
Yogyakarta .............................
..................,
2016
Hormat saya,

Bernard Zulfredo Purba

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